Characteristics and response to treatment of posttraumatic temporomandibular disorder: a retrospective study

Laser phototherapy in acute posttraumatic trismus - Case-series study

Backgroud and aims

There are very few studies on laser phototherapy (LPT) in acute temporomandibular disorders (TMDs). Our objective is to assess the effectiveness of laser phototherapy (LPT) on the limitation of the mouth opening due to an acute mandibular trauma.

Subjects and methods

Fourteen women of 41 ± 3 years and 24 men of 38 ± 3 years, with no history of TMD and having sustained a mandibular trauma within the prior 20 hours, were treated exclusively by using an 810-nm laser beam in a continuous wave mode, with an output power of 1 W. At a speed of 2 cm/s, it scanned twice, for 60 seconds, with a pause in between of 2 minutes, a large cutaneous area (25 cm²), covering the temporomandibular joint (TMJ), the masseter muscle and a part of the temporalis fossa; also, it scanned just once, for 7 seconds, a small mucous area (3 cm²), covering the internal pterygoid muscle. The clinical outcomes were evaluated by comparing the maximum unassisted opening (MUO), measured at the baseline and immediately after the end of the LPT procedure.

Results

The MUO improvement of 24.6 ± 4.4 mm represented a highly significant difference (p < .0001) between the measurements, in all the patients, regardless of gender.

Conclusions

By scanning with an 810-nm laser beam, within less than 20 hours after the trauma, large areas of all the involved tissues and not just a few points, as described until now, the limited mouth opening in acute posttraumatic trismus was immediately and greatly resolved.

The relationship of whiplash injury and temporomandibular disorders: a narrative literature review

OBJECTIVE

The purpose of this article is to offer a narrative review and discuss the possible relationship between temporomandibular disorders (TMDs) and whiplash injuries.

METHODS

Databases from 1966 to present were searched including PubMed; Manual, Alternative, and Natural Therapy Index System; and Cumulative Index for Nursing and Allied Health Literature. Search terms used included whiplash injury, temporomandibular disorders and craniomandibular disorders. Inclusion criteria consisted of studies on orofacial pain of a musculoskeletal origin addressing the following topics: posttraumatic temporomandibular disorder (pTMD) incidence and prevalence, mechanism of injury, clinical findings and characteristics, prognosis (including psychologic factors). Excluded were studies of orofacial pain from nontraumatic origin, as well as nonmusculoskeletal causes including neurologic, vascular, neoplastic, or infectious disease.

RESULTS

Thirty-two studies describing the effects of whiplash on TMD were reviewed based on inclusion/exclusion criteria. The best evidence from prospective studies indicates a low to moderate incidence and prevalence. Only 3 studies addressed mechanism of injury theories. Most studies focusing on clinical findings and characteristics suggest significant differences when comparing pTMD to idiopathic/nontraumatic patients. Regarding prognosis, most studies suggest a significant difference when comparing pTMD to idiopathic/nontraumatic TMD patients, with pTMD having a poorer prognosis.

CONCLUSIONS

There is conflicting evidence regarding the effects of whiplash on the development of TMD. Furthermore, because of lack of homogeneity in the study populations and lack of standardization of data collection procedures and outcomes measured, this review cannot conclusively resolve the controversies that exist concerning this relationship. This review of the literature is provided to clarify the issues and to provide useful clinical information for health care providers managing TMD such as doctors of chiropractic, physical therapists, dentists, and medical doctors.

[Depression and neuropsychological testing in patients with temporomandibular disorders]

A cross-sectional retrospective study was undertaken, with the primary objective of discovering if there were any neuropsychological differences among and within groups. The California Verbal Learning Test (CVLT) and the Brown-Peterson Consonant Trigram Auditory Memory Test (CCC) were used. Depression was assessed by the Beck Depression Inventory (BDI - Portuguese Version).The neuropsychological tests used did not present any statistically significant differences among the three groups studied, which might be due to the low proportion of patients with post high school education (20%). However, the experimental group (Groups I plus II) showed higher scores on depression (p<0.05) than Group III. In addition, Group II showed higher levels of depression (p<0.01) than Group I, and no statistical differences were found between Group I and III. Taken together, these results suggest that memory tests are highly dependent on the education levels of the participants and cannot be widely used. Additionally, depression plays a role not only in the etiology, but also in the perpetuation of TMD.

Radiographic and clinical features of temporomandibular dysfunction in patients following indirect trauma: A retrospective study

OBJECTIVES

Patients developing temporomandibular dysfunction (TMD) following a motor vehicle accident (MVA) have been reported to respond poorly to standard TMD treatment compared with TMD patients who have not sustained an MVA. The purpose of this study was to determine clinical and radiographic differences between post-MVA and nontrauma TMD patients and to determine whether radiographic findings in post-MVA patients undergoing litigation show more severe anatomical changes than post-MVA patients not undergoing litigation.

STUDY DESIGN

One hundred thirty-six files with magnetic resonance imaging (MRI) and/or bone scan studies of TMD patients were randomly drawn (54 post-MVA and 82 nontrauma TMD).

RESULTS

Patients with post-MVA TMD demonstrated significantly more orofacial pain complaints but significantly less disk displacements on MRI (47.5% post-MVA vs. 69.2% control; P = .03). Litigating post-MVA patients had significantly more nonreducing disks than the nonlitigating group (37.7% litigating vs. 7.7% nonlitigating; P = .05).

CONCLUSION

Based on these findings, it is suggested that treatment limited to the temporomandibular joints (TMJs) in post-traumatic TMD patients may fail without consideration that pain may originate in structures other than the TMJs. Within the post-MVA group, the more severe anatomical changes were found in the litigating patients, suggesting that some of their symptoms are associated with anatomical changes.

Sensory and affective components of orofacial pain: is it all in your brain?

In this paper, we shall review several chronic orofacial pain conditions with emphasis on those that are essentially refractory to treatment. We shall present a review of current and past literature that describes the various pain phenomena as well as their underlying central mechanisms. New data concerning refractory pain will be used to underscore the importance of central processing of pain, with particular emphasis on neuropsychological and cognitive function and capacity that may play important roles in pain processing and maintenance of the pain state. Further, neurophysiological data showing that the anterior cingulate cortex (ACC) and other structures in the brain may play key roles in modulation of chronic pain will also be discussed. Although peripheral triggering events surely play an important role in initiating pain, the development of chronic and, in particular, refractory pain may depend on changes or malfunctions in the central nervous system. These changes may be quite subtle and require sophisticated approaches, such as functional MRI, to study them, as is now being done. New findings obtained therefore may lead to more rational and reliable treatment for orofacial pain.

Temporomandibular disorders--traumatic etiology vs. nontraumatic etiology: a clinical and methodological inquiry into symptomatology and treatment outcomes

The purpose of this research is to investigate the distinctions relating to Presenting Symptoms and Treatment Outcomes between patients suffering temporomandibular disorder (TMD) as a result of traumatic versus nontraumatic etiology. A geographically diverse cohort of 1,842 patients diagnosed with TMD was investigated with special emphasis placed on the following criteria: 1. The distribution of demographic and symptom characteristics of patients with trauma as an immediate precipitating factor versus those with other nontraumatic etiologies; 2. The relationship between nontrauma status and treatment outcomes; 3. The interrelationships between nontrauma status, psychosocial factors, and treatment outcomes. Trauma patients tended to be younger, less educated, and more likely to be male than the nontrauma patients. For this group the reported length of the TMD problem was, as expected, of shorter duration when compared to the nontrauma patient group. Length of treatment did not differ between the two groups. In comparison, trauma patients reported higher initial overall symptoms including pain and range of motion limitations. However, symptoms related to joint dysfunction did not vary appreciably. Treatment outcomes are complicated by the fact that TMD encompasses several different diagnostic entities. Trauma patients reported significantly higher percentages of improvement in palpation pain and perceived malocclusion. No significant differences were found for pain report, joint dysfunction, stress, and overall TMD symptomatology, as measured by the TMJ Scale's Global domain. Trauma patients manifested higher psychological dysfunction levels (excepting stress) and showed significantly more improvement in both psychosocial function and stress than the nontrauma group.

Need for occlusal therapy and prosthodontic treatment in the management of temporomandibular disorders. Part II: Tooth loss and prosthodontic treatment

The second part of this review, evaluating the literature on the relationship between dental occlusion and temporomandibular disorders (TMDs), focuses on the aetiological importance of tooth loss and the place of prosthodontic replacement in the treatment of TMD. Loss of teeth and lack of posterior occlusal support seem to have little influence on the development of TMD, which calls into question the use of prosthodontic restoration as prevention or treatment for TMD. In addition, there are practically no studies assessing the benefit of instrumental analysis in diagnosis or comparing the outcome of prosthodontic treatment with simple reversible methods in the management of TMD. There is a trend in the current literature to abandon any treatment, including positioning appliances and prosthodontic measures, to 'recapture the disk' in patients with disk displacements because of the favourable, long-term results achieved after using more simple methods. It is concluded that prosthetic therapy in TMD patients is not appropriate for initial TMD treatment and should only be carried out on prosthodontic indications after reversible treatment has alleviated pain and dysfunction.

Temporomandibular disorder treatment outcomes: first report of a large-scale prospective clinical study

The diagnosis and treatment of temporomandibular disorders (TMD) has been surrounded by considerable controversy. Clinical research in the field to date has been inconsistent and methodologically limited and has not firmly established the role of treatment interventions. This large scale, multisite study attempts to answer some of the questions regarding TMD diagnosis and treatment. More than 6,500 patients are currently being analyzed and 1,212 have completed TMD therapy, providing the basis for comparison with 198 untreated patients. A wide variety of treatments have been administered from 60 practice sites, whose practitioners were carefully calibrated to maximize inter-rater reliability. A validated symptom measurement system, the TMJ Scale, was employed to assure uniform assessment of treatment outcomes. Treated patients reported statistically and clinically significant symptom improvement, while untreated patients reported unchanged symptom levels. Data presented here do not support the hypothesis that TMD patients improve spontaneously without treatment.

A new survey instrument: a sample of a typical TMD practice

The study evaluated 646 patients treated in a full time TMD practice with a new survey tool based on a patient self-report questionnaire. It would appear that this new approach to practice evaluation has not been previously reported in the literature. The results indicate that the average patient has a significant time delay of 24 to 120 months from onset of symptoms to the beginning therapy and that the majority of patients see three or more practitioners before reaching the TMD therapist. Most significantly, there are strong indications that early intervention and persistent compliance with prescribed therapy produces the highest level of success. Valuable practice statistics regarding patient treatments, patient outcomes and modalities of therapy have proven intensely useful in managing the patients, educating the public, communicating with the referral base, as well as in negotiating participation agreements with managed care institutions.

Whiplash and temporomandibular disorders: a critical review

Some authors have hypothesized a relationship between rear-impact motor vehicle collisions and subsequent symptoms of neck pain and temporomandibular disorders, or TMD, despite no facial impact. This article examines the TMD aspect in terms of the physiological basis and cultural factors influencing the reporting of such symptoms.

Effect of impact and injury characteristics on post-motor vehicle accident temporomandibular disorders

OBJECTIVES

The objective of this study was to assess the potential effects of motor vehicle accident impact and injury characteristics on post-motor vehicle accident temporomandibular disorders in terms of presenting signs and symptoms, diagnoses, treatment regimens, and outcomes.

STUDY DESIGN

A retrospective chart review of 50 patients with post-motor vehicle accident temporomandibular disorders from a private oral medicine practice was undertaken. Various demographic data and data related to temporomandibular disorders and motor vehicle accident impact and injury characteristics were collected. Chi-square and Fisher exact tests and multiple regression analyses were performed.

RESULTS

Patients involved in front-end collisions or motor vehicle accidents resulting in severe vehicle damage reported more direct orofacial injury. However, those in rear-end collisions or accidents resulting in minimal vehicle damage required more treatment. Direct head or orofacial injury was therefore not a prognostic indicator. From multiple regression analyses, indicators of a poorer prognosis were minimal vehicle damage, lack of headrest use, driver position, and settlement of insurance claim.

CONCLUSIONS

In this patients group several prognostic indicators for patients with post-motor vehicle accident temporomandibular disorders were identified; these indicators may influence the management approach for this patient population.

What factors affect physicians' decisions to prescribe opioids for chronic noncancer pain patients?

OBJECTIVE

To evaluate the contribution of pain severity, physical pathology, demographic factors, initiators of symptoms, affective distress, behavioral expressions of pain, and functional activity levels in physicians' decisions to prescribe opioid medication for chronic noncancer pain patients.

DESIGN

Patients were examined by a physician and physical therapist, interviewed by a psychologist, and asked to complete a medical history form and a set of self-report questionnaires. Patients who were prescribed opioids were compared with those who were not prescribed opioids on each of these. In addition, logistic regression analysis was performed to determine the best predictors of opioid prescriptions.

SUBJECTS

A total of 191 (96 female and 95 male) consecutive patients referred to a multidisciplinary pain treatment facility diagnosed with a variety of chronic pain syndromes.

RESULTS

Neither pain severity nor objective physical pathology influenced physicians' prescribing of opioids medication. Similarly, duration of pain and demographic factors had minimal impact on prescribing of opioids. Patients' behavioral manifestations of pain, distress, and suffering--pain behaviors--and reports of functional disability and distress did distinguish between patients prescribed opioid medications from those who did not. However, when all variables were entered into a logistic regression model, only observed pain behaviors showed a significant association with opioid prescriptions.

CONCLUSIONS

Physicians' practice in prescribing of opioids appears to be influenced most by patients' nonverbal communications of pain, distress, and suffering. Some of the factors not directly evaluated in this study that may also contribute to the decision to prescribe opioids for chronic noncancer pain patients are discussed.

Traumatic onset of temporomandibular disorders: positive effects of a standardized conservative treatment program

OBJECTIVE

To compare presenting problems and response to treatment of chronic temporomandibular (TMD) patients who perceive the onset of their symptoms to be related to trauma with those who report symptoms of unknown origin.

DESIGN

Prospective treatment outcome study.

SETTING

Outpatient multidisciplinary pain treatment center at a university medical center.

PATIENTS

A total of 361 were evaluated initially, including 103 who perceived traumatic onset of symptoms and 258 who did not perceive onset to be related to trauma. Two hundred thirty-three (59 trauma and 174 nontrauma) returned for follow-up evaluation 6 months after the conclusion of treatment.

INTERVENTIONS

Standardized six-session treatment program consisting of intraoral appliance, biofeedback, and stress management training.

OUTCOME MEASURES

Clinical changes in muscle pain, temporomandibular joint pain, and mandibular opening. Self-report of change in perceived pain severity (MPQ--short form), depressive symptoms (BDI), catastrophizing about pain (CSQ--catastrophizing scale), MPI--interference scale, oral parafunctional habits, global evaluation of improvement, and use of pain medications at follow-up.

RESULTS AND CONCLUSIONS

Regression of onset type on pretreatment variables indicated that a small but statistically significant proportion of pretreatment variability (8.7%) could be accounted for by onset. Both traumatic and nontraumatic onset groups showed positive outcomes following treatment. No significant differences between groups were found for any of the clinical or self-reported outcome measures with the exception that a significantly higher percentage of the trauma group reported using pain medication at follow-up. These findings are in contrast with previous suggestions that post-traumatic TMD patients show poorer response to treatment than nontrauma TMD patients.

Temporomandibular disorders, headaches, and neck pain after motor vehicle accidents: a pilot investigation of persistence and litigation effects

STATEMENT OF PROBLEM

There is a lack of long-term follow-up studies that involve post-motor vehicle accident temporomandibular disorders and compensation.

PURPOSE OF STUDY

The purposes of this retrospective pilot study were (1) to assess patients who had previously been treated for temporomandibular disorders after motor vehicle accidents to determine the nature of their symptoms in terms of jaw, head, and neck pain and jaw dysfunction and (2) to determine whether there was a difference in the pain and dysfunction between those who had settled and those who had not settled their insurance claims.

MATERIAL AND METHODS

Thirty previously treated patients with temporomandibular disorders after motor vehicle accidents were questioned by telephone regarding litigation status and current jaw, head, and neck pain and jaw dysfunction symptoms. They did not differ substantially from a smaller group who were not able to be interviewed. Descriptive statistics were calculated and statistical tests were performed. A total of 22 patients had their claims settled.

RESULTS

Approximately three fourths had persistent complaints of jaw pain, jaw dysfunction, and headache, and more than 80% reported persistent neck pain. No apparent differences were found between those who had and had not settled their insurance claims.

CONCLUSION

Jaw, head and neck pain, and jaw dysfunction continued to be problems for the majority of this patient population, regardless of litigation status in this retrospective study.

A retrospective evaluation of the impact of temporomandibular joint arthroscopy on the symptoms of headache, neck pain, shoulder pain, dizziness, and tinnitus

Forty-three patients who underwent arthroscopic surgery for arthrogenous TMD were polled concerning the effect of surgery on the symptoms of headache, neck pain, shoulder pain, dizziness and tinnitus. Statistically significant levels of symptom reduction were recorded for all symptoms polled. This indicates that a substantial number of significant symptoms are produced by the influence of temporomandibular joint pathology on central neural processes. A model for the affect of temporomandibular joint pathology on cervical and masticatory musculature is proposed. This data implies that we cannot use muscle tenderness, hypertonicity and/or pain to differentiate arthrogenous from myogenous temporomandibular disorders. The characteristics of a population of whiplash onset TMD patients were compared to other TMD populations. The results indicate that whiplash induced TMD may differ from insidious onset TMD and even other trauma onset TMDs by prevalence of neck pain, intensity of neck pain and probability of concurrence of neck pain, shoulder pain, headache and jaw pain. These symptoms resolved within 24 hours of arthroscopic temporomandibular joint surgery indicating that the temporomandibular joint pathology was the perpetuating force behind, if not the cause of, these symptoms.

Diagnosis and treatment of persistent pain after trauma to the head and neck

PURPOSE

A retrospective and prospective study on 22 cases of persistent pain after trauma to the head and neck is presented. According to the predominant symptoms and signs, pain patterns could be divided into musculoskeletal, vascular, and neuropathic, facilitating treatment decisions. Most cases were musculoskeletal in origin, with many demonstrating a combination of two or three pain states.

RESULTS

The variety of pain complaints and their underlying pathophysiology are discussed and treatments for specific pain states are examined.

CONCLUSION

Amitriptyline was the most useful drug in that it provided pain relief in musculoskeletal, vascular, and some neuropathic pain conditions. Multidrug therapy may be indicated in some recalcitrant cases, and drug alternatives are discussed.

Evidence for construct validity of the TMJ scale in a sample of chronic post-traumatic headache patients

The construct validity of the TMJ Scale was examined in a sample of chronic post-traumatic headache patients. Clinical indicators of temporomandibular (TM) dysfunction and measures of psychosocial distress were compared with relevant scales of the TMJ Scale. The clinical indicators were first subjected to principal components analysis. The resulting factor scores correlated significantly with selected physical domain scales of the TMJ Scale. The factor scores also significantly predicted the TMJ Global Scale in a regression analysis. Selected psychosocial domain scales of the TMJ Scale correlated strongly with measures of depression and anger and a clinical diagnosis of post-traumatic stress disorder. The results support the validity of the TMJ Scale and demonstrates its utility with post-traumatic headache patients.

A year of chronic TMPDS: evaluating patients' pain patterns

In 136 women with TMPDS observed for one year, pain was highly variable. No respondent had a consistent pattern of pain increase or decrease.